The patient  a Libyan citizen, came to the clinic 19-May-2012 from Al-Hayat Hospital complaining of fainting attacks and headache for 3 months and swallowing problems. For one month start to show rapid progression of left sided paresis, due to what he suffered RTA one week ago and after that progressed complete right sided plegia with motor and sensory aphasia.

On examination, the patient was brought in stretcher, communication with difficulty with no sensory deficit. The power of the right side is normal.

MRI of the brain done 16-May-2012 showing huge glioblastoma multiforme occupying the right frontal and temporal lobes. Even his son is a doctor, but the total aphasia could be explained only by that is he is left handed.

Due to  bureaucratic reasons the surgery was delayed and the patient condition deteriorated more, for what, another MRI was done 14-June-2012 to rule out the invasion of the brainstem. Starting uncal conning was noted in the new MRI.

Using INAV Medtronic and OPMI Pentero 900, right fronto-temporal approach was achieved with reflection of the flap to the ear. Practical temporal lobectomy was done with the rubbery consistency tumor was followed and resected. Even the right sylvian cistern was under visual control, a piece of the rubbery tumor was left intentionally due to clustering with right M1 and its branches to avoid possible postoperative spasm. Broca area and the frontal lobe looked healthy. The Wernicke area was left untouched after resection of the rubbery part of the tumor. That part extending to the internal capsule was also respected and left behind. Tease maneuvers were done with INAV. The inferior horn of the temporal lobe was violated, but surgicele was embedded there to prevent CSF flow. The tentorium was inspected and the uncal part was resected to avoid further uncal herniation. 16 pieces of Gliadel wafers were applied to the tumor bed and surgicele was put over it to prevent its migration. Strict heamostasis. About 90% of the surely tumor mass was resected.

Routine closure of the wound. Smooth postoperative recovery. The patient became more vivid and the power of the left lower limb became better and the patient is opening eyes and trying to produce sounds.

Immediate brain CT-scan done showing the extent of resection and decrease of swelling .

The patient has eminent conning. Surgical decompression and application of Gliadel wafers is the best option in this case.